10-1131 (ELEC)ii" _ r
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Ta!t 4 4 Q"
Applicant: Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
--------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm under penalty of perjury that I a icensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business a ro0`ss7oq6 Code, and my License is in full force and effect.
License Class: B L ense No.: 915336
Date: � ontract
WNER-BUILDER DECLARATION
hereby affirm under penalty of perjury that I a exempt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and P essions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
. improve for the purpose of sale.).
(_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
. CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/28/10
Owner:
EAST OF MADISON LLC
PO BOX 1482
LA QUINTA, CA 92247 r �
Contractor: t 8
DBCA INC 2L;� ! t
P.O. BOX 1482
LA QUINTA, CA 92247 ~ `' -:,d• r.:: `':%z;r ~� /
(760) 793-5271
Lic. No.: 915336 _
------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
1` I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier TRAVELERS PROP Policy Number YEU13282D779708
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as t become subject to the workers' compensation laws of California,
and agree that, if I should b me t to the workers' compensation provisions of Section
�( 3700 of the Labor Code, I II fo hwith mply with those provisions.
iDate: V • '�d plicant-
WARNING: FAILURE TO SECURE WORKER COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PE LTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO T COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. '
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1 . Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the abov i rmaY is correct. I agree to comply with all
city and county ordinances and state laws relating to building c s ctio , an reby authorize representatives
of this county to enter upon the above-mentioned property for i p do rposes.
�l • {b Siature (Applicant or Age
�
Application Number:
10---00001131=
Property Address:
52865 HUMBOLDT BLVD
APN:
767 -680 -012 -
Application description:
ELECTRICAL
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
500
Ta!t 4 4 Q"
Applicant: Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
--------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm under penalty of perjury that I a icensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business a ro0`ss7oq6 Code, and my License is in full force and effect.
License Class: B L ense No.: 915336
Date: � ontract
WNER-BUILDER DECLARATION
hereby affirm under penalty of perjury that I a exempt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and P essions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
. improve for the purpose of sale.).
(_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
. CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/28/10
Owner:
EAST OF MADISON LLC
PO BOX 1482
LA QUINTA, CA 92247 r �
Contractor: t 8
DBCA INC 2L;� ! t
P.O. BOX 1482
LA QUINTA, CA 92247 ~ `' -:,d• r.:: `':%z;r ~� /
(760) 793-5271
Lic. No.: 915336 _
------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
1` I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier TRAVELERS PROP Policy Number YEU13282D779708
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as t become subject to the workers' compensation laws of California,
and agree that, if I should b me t to the workers' compensation provisions of Section
�( 3700 of the Labor Code, I II fo hwith mply with those provisions.
iDate: V • '�d plicant-
WARNING: FAILURE TO SECURE WORKER COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PE LTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO T COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. '
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1 . Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the abov i rmaY is correct. I agree to comply with all
city and county ordinances and state laws relating to building c s ctio , an reby authorize representatives
of this county to enter upon the above-mentioned property for i p do rposes.
�l • {b Siature (Applicant or Age
-Application Number. . . . . . 10-00001131'
Permit . ...
ELEC-TEMPORARY POWER
Additional desc .
Permit Fee . . .
. 30.00 Plan Check Fee
.00
Issue Date
Valuation . . .
. 0
Expiration Date
4/26/11
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 15.0000 EA ELEC TEMPORARY POWER POLE
15.00
----------------------------------------------------------------------------
Special Notes -and
Comments
TEMP POWER POLE FOR NEW CONSTRUCTION.
2007 CODES.
-----------------_----------
Other Fees .
-----------------------------------
. . . . . . BLDG STDS ADMIN (SB1473)
-
1.00
Fee summary
Charged Paid Credited
Due
-----------------
Permit Fee Total
---------- --------
30.00 .00 .00
30.00
Plan Check Total
..00 .00 .00
.00
Other Fee Total
1.00 .00 .0.0
1.00
Grand Total
31.00 .00 .00
31.00
LQPERMIT
Din #
- - = CXY Of L Quints
PeMJt \� �� P.O. Box I SD4, 78-495 Cage Tampko
} la Qldnta, CA 92253 - (760) 777-7012
Building Pennit Application and Tracidng Sheet
Prqjecc Addrm- X28 a � 52�vy �l o owttor't Namta
A - P. Number: 7(07-E70-401 � QF�/S? G
Conuwtoc: Y. ST, zip: [!r '111A110 a %12 7 3
09 Sz �7 iolm
CD2 azo 718
Address: ��
3- -JIMM
City. ST, Zip: . � l� v�iv�
TelcPhonc: �� �B Pow W
Sbft Lic. #: //NJ6: �QQ� 7 R. 5�j;r
Lia D: r� CV '"J�ZZ7�OS Pv��t%1_
Ar&_ �� Dam;
Adams ! ��ST pd 14P )WeF P OF
City. ST. Zip:
Tdebae. 76a
•��-X707
State LtC .
Name ofconbact Persm. 1
Tdephony d of Contact Ptrsoo:
B 8abratthl
Ptaa Sds
Strudnn d Cela.
Ttma Cath.
Title u Cala,
Flood plain plan
Grading pian
Subeontaetur Last
Grant Deed
H.O.A. Approval
IN HOUSE:_
Planatng Approval
Pub. Wks. Appr
School Feet
Rtc`d
52805
Date of permit issue
Total Penult Foes
Coattrugion Type:
`y: —
�ax type (Cmk ono): Now Add`n Ab w Rqw Dano
EV/91577
sq. PL:
d stories:
IT Units:
Zea.- -11b 3
1-*Matod
Valu of Pmjeet:
"ICANT: DO NOT WRITE BEWW THIS UNE
i1tACKING
PBB1YtIT FBES
Plan Check mbmiftd
Item Asionat
Rerierred, ready for roe eeHoss
PhaCbt&
Ca&d Contact Person
Plan Chedk Baling
Pk= picked up
Cb=tmctton
Plass resnbmleted
tYiechaakal
2'! Rerkrr, ready for eorredloos/iune
EkebUdl
Called Oontsct Person
Plum
Plans pickedap
SJA L
Plans rtsdmitted��
Review, ready for eormctloaslissae
Developa Impact Fte
Called Contact Puson
AJXZ.
Date of permit issue
Total Penult Foes
Pno t000.o 1 P,ao•, 79.o / /\/\ ` •� dd1 \ I ( \, \11 �E
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' GRAPHIC SCALE
• 1 i
/
7595 W- ca- 0, CITY OF LA QUINTA DRAWING NAME:
IrNna 9.4926111 1.�' FO ItFA_l1p32 THE MADISON CLUB
uc EH -0H -VILLAS
Pa00e: 949.450111 MLI i
� Fse9.455.oanD PROJECT No.
Consultants Inc. �%F g v Q~ CLUBHOUSE AND VILLAS EXHIBIT o001 MDC
SCALE: FILE No. DATE 111 SHEET 1 OF 1
1' = 50' 0502 01/02/08
i